Background: Internationally, emergency medicine (EM) physicians are vulnerable to both physical and verbal violence. Few studies have examined or compared perceptions and the impacts of workplace violence in India and the United States (US).Objectives: To assess the perceived incidence of workplace violence and its implications on sleep, missed days of work, fear in the workplace, and overall job satisfaction.Materials and Methods: This was an anonymous, prospective, cross-sectional electronic survey of EM residents and physicians. A cohort of physicians in the US was matched to a cohort of physicians in India.Results: Overall, 286 physicians were eligible to participate, 177 responded (98 people from the US and 79 from Indian, for a 62% total response rate). In the US 100% of respondents witnessed verbal violence, whereas only 23% of verbal abuse cases were reported. In India, 89% of respondents witnessed verbal abuse, 46% of cases were reported. Respondents in the US both witnessed and experienced significantly more verbal and physical abuse (P < 0.001). Despite the differences in perceived rates of violence, there were no significant differences between country cohorts regarding the consequences of these incidents. This includes self-reported sleep, missed days of work, and fear of going to the workplace. US respondents were less satisfied with their jobs due to workplace violence as compared to their Indian colleagues (P = 0.041).Conclusion: ED workplace violence is common internationally, underreported, and results in poor job satisfaction, workplace fear, and loss of sleep.The following core competencies are addressed in this article: Patient care, Professionalism, Systems-based practice.

Violence in the workplace is a serious and concerning issue worldwide. The World Health Organization (WHO) estimates that in healthcare between 8% and 38% of health workers suffer physical violence at some point in their careers.[1] Actual occurrences verbal violence are difficult to quantify as these issues often go unreported.

There are enormous emotional, physical, and monetary costs of violence at work for employees, the workplace at large, and the surrounding community. This is particularly true in developing countries where resources and personnel are already scarce. The goal of equal access to primary health care for all is at risk wherever the workforce delivering these services feels threatened.[1] These threats are particularly evident in geographic areas of general conflict and in work environments where transport to work, shift-based work, and exposure to late hours make the threat of violence more concerning. The emergency department (ED), in particular, is a workplace prone to violence given the high-risk nature of acute care and the magnitude of stressors present in emergency medical settings.,[2],[3],[4],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14],[15] In many countries, the healthcare and nursing workforces are primarily female employees, adding a gender dimension to the problem.[1]

Many definitions of “workplace violence” exist in the literature, making comparisons between studies difficult. These multiple definitions also cause significant discrepancies in the reported frequency of violence. Violence is generally defined as being destructive toward another person and can be in the form of physical assault, verbal abuse, bullying, sexual harassment, or mental stress.[16] Several prior studies have limited their definition of the term to include only actual or attempted physical assault.[17] Other studies have defined the term to include any form of behavior that is intended to harm current or previous employees or their organizations as a whole.[18]

To accurately collect information regarding all aspects of workplace violence and their consequences, this study will use the broader WHO definition of the term, as follows: “The intentional use of power, threatened or actual, against another person or against a group, in work-related circumstances, that either result in or has a high degree of likelihood of resulting in injury, death, psychological harm, maldevelopment, or deprivation.”[19],[20]

Most existing data on workplace violence are from a subset of countries and locations that include the United States (US), the United Kingdom, and Australia. These countries also have in place serious legal consequences and support structures to prevent workplace violence altercations. Despite these regulations, acts of violence are often underreported, and ED employees have developed the perception that these events are part of the usual environment of emergency medical care. Few studies have compared perceptions of workplace violence between countries, and little data exist regarding workplace violence specifically in the healthcare sector in India and other developing countries.[1]

We sought to assess the perceptions of workplace violence experienced by faculty and residents/junior physicians working in select EDs in the US and India. The results of this study may be used to design improvements in staff support systems; to explore the economic impact of workplace violence on lost wages due to time off from work; and to quantify decreased productivity due to emotional repercussions such as depression, anxiety, and loss of sleep or job satisfaction. Last, we sought to determine differences in the impact of violent incidents based on country, gender, and level of training.

Materials and Methods

Study design and setting

This study was a cross-sectional survey of emergency physicians in the US and India. In the US, data were collected from residents and attending physicians of 4-year residency programs from two Urban Teaching Hospitals in Brooklyn, New York. In India, data were initially collected from emergency physicians in Kerala, India, at the Jubilee Mission Medical College and Research Institute. The data set was eventually expanded to include Indian emergency physicians from two courses: A Spring 2016 Board Review course and a Spring 2016 Pediatric Ultrasound course at Jubilee Mission Medical College. The survey was modeled after multiple recent large-scale studies on ED workplace violence.[5],[21],[22] The Institutional Review Board for the Protection of Human Subjects (IRB) at SUNY Downstate Medical Center as well as the IRB at Jubilee Medical College both granted expedited approvals of protocols and waivers of informed consent.

Selection of participants

All physicians working in ED s at participating institutions who had graduated from medical school were eligible for inclusion. In our US institutions, 182 residents and house staff members were eligible for inclusion. In our Indian institutions, 25 house staff members were eligible. To more appropriately, match Indian physician numbers to those in the US, we broadened the eligibility of the Indian study arm to include 50 Indian emergency physicians who participated in a Board Review Training Course at Jubilee Medical College, as well as an additional 25 Indian physicians who participated in a Ultrasound Review Course at INDUS Emergency Medicine (EM) in New Delhi, India. These physicians came from multiple states in India, with the majority hailing from the Southern region of the country.

Methods of measurement

We developed a survey tool to examine perceptions of workplace violence based on a compilation of previously validated and published tools.[5],[21],[22] To facilitate scientific replication and comparison, as well as ensure a well-validated methodology, we used the same variable definitions of workplace violence and violence types throughout the study, and we designed our survey tool to allow for comparison of prior data collected in the US. Our survey consisted of 24 multiple-choice questions. The study's primary outcomes were self-reported incidents of verbal abuse, physical abuse, and confrontations outside of a patient encounter. We additionally looked at self-perceptions of the impact of this abuse on the respondent. Demographic questions queried participants on gender, level of training, and workplace location. [Appendix 1] is the tool we utilized for data collection.

Data collection and processing

We created our electronic survey using Google Form, with a physical form matching the electronic version created for participants unable to complete the survey electronically (i.e., participants in India without access to the internet). All physical survey data were then entered verbatim into the electronic forms by staff members at Jubilee Medical College.

In the US, we sent e-mail invitations to the EM house staff list-serve with a link to the survey on Google Form. These emails were sent during five consecutive weeks in July and August 2015 and included weekly reminders about survey completion for the duration of the study. The US survey closed at the end of August 2015.

In India, we distributed both e-mail invitations and matching paper surveys to all Jubilee EM house staff, EM board review course participants, and emergency physicians in the ultrasound workshop. The India data were collected from October 2015 to February 2016. Data collection in India ended when the total number of respondents was comparable to the total number of US respondents.

In all locations, survey completion was voluntary, and no incentives were provided for participation.

Primary data analysis

Minimum sample size determination was established using Sample Power 3.0 (SPSS, Inc., Chicago, IL, USA). To determine responses within ±5% of true population value, we used a baseline population size of 382 people (the total number of EM physicians who qualified for our study), a confidence interval of 5%, a standard of deviation of 50%, and confidence level of 95%, resulting in a required sample size of 163.

We collected all survey responses in Google Forms (Google, Alphabet Inc.) and calculated statistics using Google Sheets (Google, Alphabet Inc.). We used Pearson's Chi-square test to compare selected differences in nominal and ordinal outcomes between subgroups, including gender (male/female), country (US/India), and levels of training (resident/attending). For all analyses, P < 0.05 denotes statistical significance, with no adjustment for the multiple comparisons.

Results

Out of the 286 physicians who were eligible to participate from both countries, we received 177 responses (62% response rate). In the US, 98/182 eligible physicians completed the survey (54% response rate). In India, 79/100 eligible physicians completed the survey (79% response rate).

Respondents included 62 females (35%), 110 residents (within the first 4 years of graduation from medical school) (62%), and 67 attendings (had worked for 4+ years) (38%). [Table 1] shows a full summary of respondents' demographic data.

Verbal abuse in the workplace was witnessed by 100% of US respondents and personally experienced by 92.9%. However, only 23% of verbal abuse cases were reported. Verbal abuse occurred daily, according to 44% of US respondents. Participants indicated that almost all of these threats (99%) came from patients or patients' families, with only one threat coming from other ED staff members.

Physical abuse was witnessed by 83.7% of US respondents and personally experienced by 38.8%, with. 34% of the witnessed physical abuse cases reported.

Physical abuse occurred every 6 months, according to 29% of US respondents. All physical abuse incidents involved patients or their families.

Confrontations outside of the ED were reported by 17.3% of US respondents, with 15.3% of respondents having had a weapon brandished at them sometime during their medical career.

Abuse resulted in 66% of US respondents feeling less satisfied with their job due to workplace violence, with 12% feeling afraid to go to work due to these incidents, 15.3% losing sleep at night due to workplace violence, and one US respondent missing work due to an incident of workplace violence.

Among US respondents, gender-based comparisons yielded no significant differences except in response to “Have incidents of workplace violence made you to be less satisfied with your job.” For this question, women were statistically more likely to respond “yes” (81%) than men (55%) (P< 0.010).

In addition, among US respondents, there were statistically significant differences between attendings and residents in affirmative responses to the questions “Have you had a weapon brandished?” (attendings 26%, residents 10%, P = 0.018) and “Have you lost sleep?” (attendings 21%, residents 6%, P < 0.001).

Verbal abuse in the workplace was witnessed by 89% and personally experienced by 70% of Indian respondents. Respondents acknowledged reporting 46% of verbal abuse cases. Verbal abuse occurred daily (5%), weekly (22%), monthly (45%), every 6 months (21%), and yearly (5%), according to Indian respondents.

Participants indicated that the majority of these threats (89%) came from patient families, with 30% of threats stemming from patients. Unlike in the US, a significant percent of verbal threats came from other ED staff members and hospital consultants (17%) (Note that the reported sources of verbal threats are not mutually exclusive categories.)

Physical abuse was witnessed by 37% of Indian respondents and personally experienced by 4%, resulting in a total of thirty physical abuse cases. Of these, 17% were reported. Physical abuse occurred daily (3%), weekly (13%), monthly (17%), every 6 months (50%), and yearly (17%), according to Indian respondents.

Furthermore, most physical abuse incidents (97%) involved patients or their families; only one incident (3%) involved another ED staff member.

Confrontations outside of the ED were reported by 11% of Indian respondents, with 4% having had a weapon brandished at them, sometime during their medical career.

Abuse resulted in 46% of Indian respondents feeling less satisfied with their job due to workplace violence, 14% feeling afraid to go to work due to these incidents, 22% losing sleep at night due to workplace violence, and 4% missing work due to an incident of workplace violence.

In India, women reported witnessing less verbal violence than men (74% vs. 93% P = 0.01). However, this was the only significantly different response between genders or based on the level of training within the Indian cohort (all P values from 0.08 to 1.0).

While both cohorts reported having experienced large amounts of violence, respondents in the US both witnessed and experienced significantly more physical and verbal abuse (P< 0.001). In addition, US respondents were 20% more likely to report being less satisfied with their job due to the incidents of workplace violence (P = 0.041).

Regarding the perpetrators of abuse, in India, there was a statistically greater chance of verbal violence originating from a hospital-affiliated source (1% of verbal abuse incidents in the US vs. 17% of verbal abuse incidents in India, P = 0.01). We did not find a statistical difference between the rates of weapons being brandished against physicians between countries (US 15% vs. India 4%, P = 0.062) although this appears to trend toward significance.

Despite the large differences between perceived rates of verbal and physical violence, there were no significant differences between country cohorts regarding the consequences of these incidents on self-reported sleep, missed days of work, or fear of going to the workplace. There was a slight increase in US respondents indicating that they were less satisfied with their jobs due to workplace violence as compared to their Indian colleagues (P = 0.041).

Our findings mirror the similar studies describing ED violence, which is common and has significant psychological consequences for employees. Our study reinforces that more must be done to prevent violence and increase the mental and emotional support structures for physicians who experience workplace violence.[2],[3],[4],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14],[15]

While numerous studies have examined and reported results related to ED workplace violence in the US,[1] there are minimal data available on the rates of workplace violence in EDs in India. Our study demonstrates that while these issues may be slightly less pervasive in India compared to the US, the effects of these incidents on workplace morale and physicians' mental health are nearly identical.

In the US, multiple attempts have been made to quantify the effects of workplace violence, with data sources ranging from a recent single-center prospective study to national investigations encompassing 65 EDs that are part of the National Emergency Department Safety Study.[5],[23] However, most of these prior findings cannot be directly compared due to their multiple competing definitions of workplace violence, as well as their use of different instruments/surveys. Furthermore, most previously published studies reflect reports from administrative personnel as opposed to individual ED staff members.[6] Only in the previous 5 years has research begun differentiating between incidences of verbal and physical violence and the occurrence of workplace violence as a whole as well as started using standardized definitions of workplace violence. We designed our survey using these standardized definitions to better compare our results to the previous findings.

One of the most problematic findings in our study is that over half of all respondents across both countries noted that workplace violence has made them less satisfied with their jobs, with nearly one in five respondents having lost sleep as a result – a similar outcome in both country cohorts. Such responses imply significant burdens on the mental health of emergency physicians and detrimental downstream consequences on the efficient functioning of our EDs.

Our results are consistent with prior large-scale studies in the US that found that nearly 10% of all emergency physicians have had a weapon brandished against them while at work.[21] Prior rates of comparison for weapons in India are not available. We discovered that the incidence of weapon brandishment was less frequent in India compared to the US (4% vs. 15%), which was close to reaching statistical significance (P = 0.062).

We did not find any statistically significant difference in the proportion of different types of violence experienced by gender. Studies to date have often (but not consistently) found that women are more often subjects of workplace violence. These prior studies often focused exclusively on nurses or have not differentiated between types of employees in on the ED. Of interest, we did find that the answer to “Have incidents of workplace violence made you feel less satisfied with your job?” was significantly different between women and men (US women + Indian women = 69% vs. US men + Indian men = 50%). This difference was driven in part by the total number of women in the US cohort who responded “yes” (81%, n = 35).

An interesting trend emerged when we stratified the incidence of workplace violence across both gender and country. In the US, we found that women most often reported witnessing and experiencing physical violence compared to men. However, in India, we found the inverse to be true, with men more likely than women to experience verbal violence as well as physical violence. While these differences did not reach statistically significance, these trends suggest that in the US, women are more frequently the targets of violence; while in India, men are the usual targets, perhaps due to underlying cultural differences between countries.

We found that despite large discrepancies between countries in perceived rates of verbal and physical violence, there were no significant differences regarding the actual consequences of these incidents. Even though rates of violence are different in the US and India, the effects of this violence on self-reported sleep, missed days of work, or fear of going to the workplace are statistically indistinguishable. This finding suggests a threshold effect of workplace violence whereby above a certain level, workplace satisfaction is compromised, and job productivity is impaired.

Finally, our results indicate that all emergency physicians at our two US institutions (100%) have witnessed or experienced a violent act. In the US cohort, the 23% rate of reported physical violence is consistent with previously published WHO estimates.[1] Actual rates of workplace violence (both verbal and physical) for emergency physicians are reported to range from 76% to 96% and from 51% to 100% for nonphysician personnel.[7],[14],[23] Our findings suggest that the problem of workplace violence for emergency physicians, in particular, may be more pervasive than previously documented.[1]

Limitations

As with all survey data, our instrument may be subject to inherent recall bias when respondents are asked to reflect on prior incidents, with additional survey data relying on perceived rates of events as opposed to actual incidence rates. In addition, the participant population was limited to house staff in two US academic Level 1 trauma institutions and one institution in India. Therefore, the results we received from the subset of this population may not be widely generalizable.

Conclusion

Workplace violence in the ED is a pervasive issue in both the US and India, with large numbers of physicians reporting having experienced various types of violence. This study illustrates the need for further research and training regarding violence against emergency physicians, both nationally and internationally. Significant mental stress among ED practitioners is attributed to workplace violence, with potential financial impact to our institutions due to lost productivity of our ED workforce. While much work remains to decrease the incidence of workplace violence, it is critically important that institutional efforts are made to assist the ED workforce in coping with this common problem.

Kraus JF, Blander B, McArthur DL. Incidence, risk factors and prevention strategies for work-related assault injuries: A review of what is known, what needs to be known, and countermeasures for intervention. Annu Rev Public Health 1995;16:355-79.

The 2017 Academic College of Emergency Experts and Academy of Family Physicians of India position statement on preventing violence against health - care workers and vandalization of health - care facilities in India